The need to reinvent primary care

Primary care is "first-contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease, or organ system." High-quality primary care has been associated with improved population health, lower costs, and greater equity. Despite this evidence, primary care has been consistently under-resourced, accounting for just six to eight percent of US health care expenditures. Newer payment models introduced under the Affordable Care Act raised expectations, but even those modest gains appear threatened under the new administration in Washington. It is unrealistic to anticipate a significant influx of resources into primary care anytime soon. A special issue of the Journal of General Internal Medicine, just published, takes a look at primary care today.

Thus, at least in the short term, physicians, patients and policymakers interested in supporting a more comprehensive, dynamic and thriving primary care sector in the United States cannot depend wholly on the federal government. Fortunately, there is still much that can be done. We need to look to new models that deliver a better care experience, achieve better population health outcomes, and control costs. In short, we need to reinvent primary care.

In this issue of the Journal of General Internal Medicine, six articles review the current landscape of primary care innovation; stimulate thinking on new directions for primary care; and begin to construct an agenda for energetic reform. In the first article, Ellner and Phillips provide a roadmap for primary care reinvention. In the next piece, Shrank discusses how new primary care delivery models, harnessed to changing consumer expectations, can lead to more patient-centered care. An article by Hochman and Asch contrasts two divergent approaches to caring more effectively for vulnerable, high-need, high-cost populations: specialized clinics and complex case management. Kroenke and Unutzer review the body of evidence supporting collaborative care models for improving quality of mental health services delivery in primary care. Young and Nesbitt offer hope that technology can extend the reach and enhance the effectiveness of PCPs as they strive to manage the health care needs of a defined population. Finally, Cassel and Wilkes focus on one aspect of the primary care workforce development problem: nurturing student interest in primary care during medical school.

The common thread in these six articles is the importance of preserving and supporting trusting, longitudinal relationships between patients and competent, caring primary care physicians who are committed to their well-being. Other relationships are also vital, including those involving office staff, subspecialists, mental health consultants, and complex care management teams. An accompanying editorial by Kravitz and Feldman concludes that systems that support and nurture these human relationships will thrive; those that ignore them will ultimately falter.